Healthcare Provider Details

I. General information

NPI: 1215130810
Provider Name (Legal Business Name): FAYETTE CREED WILLIAMS D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2007
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 SAINT LOUIS AVENUE HOUSE STAFF & GME
FORT WORTH TX
76104
US

IV. Provider business mailing address

1625 SAINT LOUIS AVENUE HOUSE STAFF & GME
FORT WORTH TX
76104
US

V. Phone/Fax

Practice location:
  • Phone: 817-927-1325
  • Fax: 817-927-1035
Mailing address:
  • Phone: 817-927-1325
  • Fax: 817-927-1035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number21161
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: